Provider request form

All fields must be filled out to be considered for inclusion in the ADRC database.
If there are multiple programs within your agency, please complete a Program Application (separately) for each program and an Agency Application for the main administrative agency (i.e. if there are 3 programs under one umbrella agency, complete 4 applications). Incomplete applications cannot be processed.

General Information

1. Agency Name:

*Please review definition of agency vs. program found at the end of this application.

Please indicate if no one will be denied service for inability to pay.

Quality

33. Is your facility licensed or accredited?YesNo

Licensing Body:

License Date:

License #:

(If yes, please include copies of licenses and accreditation certificates with this application.)

Administrative

The following information is required for future updates.34. Note that the Update Person is the person that is completing this form and/or the person that will be providing information in the future.

Update Person Name:

Title:

Update Person's Email:

Update Person's Phone:

(If yes, please include copies of licenses and accreditation certificates with this application.)

ADRC of Oregon is collecting this information to include in a public resource database for community information and referral. This information will be reviewed to ensure the services meet the eligibility for inclusion. We reserve the right to make changes in order to ensure compliance with database style and indexing needs.

*Agency: The agency is the main location of the resource where the administrative functions occur, where the organization's director is generally housed and where it is licensed for business. An agency may or may not deliver direct services from this location.

*Program: We differentiate "programs" from "agencies" when an agency provides a group of unique services, with different sites of operation, eligibility, program contacts, etc. and organizes them as their own "program".

If you have questions or concerns, please contact us by email or call 503-988-8178.